What’s Important: Operating Room Waste

Abstract

Have you ever seen a mountain of materials for disposal atop a case cart following a surgical case and wondered, “Is all this waste necessary?” After thinking about this and then digging deeper, we have come to find that the U.S. health-care system produces a tremendous amount of waste—nearly 4 million tons (3.6 million metric tons) of solid waste per year according to a 2010 estimate—while also producing 8% to 10% of total greenhouse gas (GHG) emissions in the U.S1,2. Health-care waste is expensive to properly dispose of, and our landfills are quickly overflowing. There is a need for increased attention to waste management in an effort to decrease the effect of health care on climate change. Waste Sources and Disposal Health-care waste is defined by the World Health Organization as “the waste generated by health-care establishments, research facilities, and laboratories. In addition, it includes the waste originating from ‘minor’ or ‘scattered’ sources—such as that produced in the course of health care undertaken in the home (dialysis, insulin injections, etc.).”3 This waste often is further broken down into general or nonhazardous waste, which accounts for 75% to 90% of health-care waste, and clinical or hazardous waste, which accounts for the remaining 10% to 25% of waste3. Hazardous waste is anything that poses a health risk, including potentially infectious materials, sharps, pharmaceuticals, and radioactive materials. Differentiating general waste from hazardous waste is important because the disposal of hazardous waste is far more energy-consuming and expensive. Hazardous waste is most commonly incinerated, a process that requires high energy input and produces substantial GHGs, estimated at 3 kg of carbon dioxide (CO2) for every 1 kg of hazardous waste4. Hazardous waste accounts for up to 86% of waste costs5. General waste from hospitals is disposed of in whatever fashion the local community facilitates, often in landfills. Waste in the Surgical Setting Of interest to surgeons, between 20% and 33% of hospital waste is attributed to operating rooms (ORs)6. Hazardous waste is generally disposed of in red bags, while general waste is disposed of in clear bags. The use of this bagging system is well intentioned but fails to appropriately separate waste; up to 90% of OR general waste is improperly designated as hazardous waste7. The role of sorting waste appropriately falls onto many parties as everyone in the OR has access to the waste containers and actively disposes of waste throughout a surgical case. Proper sorting of waste is crucial. In orthopaedics, operative supplies and instrumentation vary widely among the subspecialties, which, in turn, has led to differences in the both the type and quantity of produced waste. For example, Kooner et al. found that arthroplasty produced significantly (p < 0.05) more waste per case than all other subspecialties, but also generated the largest amount of recyclable waste by mass8. In contrast, upper-extremity procedures produced the least amount of OR waste per case, and the percentage of waste that was recyclable was lower than that for arthroplasty (23% versus 33%). Other factors also may influence the waste that is produced within the subspecialties, such as differences in the average number of procedures performed each day. Regardless of subspecialty, there is room for improvement of waste management in orthopaedic surgery. This improvement could lead to both cost savings and waste reduction. A Greater Role for Reusables? The use of instruments, personal protective equipment (PPE), drapes, and OR accessories that are reusable has varied in recent decades. Current practice in many medical centers involves a heavy reliance on disposable (single-use) equipment, both for ease of use and to lower infection risk. This reasoning is controversial, however, as even the choice to use disposable draping versus reusable draping is of questionable benefit in reducing the risk of infection9. At the same time, the decreased use of disposables has demonstrated cost savings and waste reduction2, both of which are appealing outcomes as our health-care systems move to be more environmentally and economically conscious. Given the increased use of PPE, most of which is disposable, during the COVID-19 (coronavirus disease 2019) pandemic and the resulting shortages, the need to find viable, reusable medical equipment is ever present. In implementing reusables, health-care systems may also be able to insulate themselves from future shortages. Recycling in the OR Recycling is a well-known concept; however, it is not optimally practiced. In total, it is estimated that plastic packaging comprises 25% of hospital waste in the U.S., generating 1 million tons (0.9 million metric tons) annually10. Plastics that are commonly used in health care are not economically viable for processing by the U.S. recycling industry11,12. This, in addition to the fear of contamination, adds difficulty to initiating the recycling of health-care waste with recycling vendors. However, the large quantities of plastics that are produced by hospitals have the potential to create a large, consistent feedstock of recyclable material for the growing plastics recycling industry13. Successful recycling practices also are dependent on the education of health-care workers who are in charge of sorting materials, hospital logistics to appropriately collect and store the materials, and hospital-vendor relations to ensure that the materials are transported accordingly to be reprocessed into a reusable material14. Current Regulations and Practices In the U.S., the Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) define hazardous medical waste by the material and its degree of contamination because treating all potentially contaminated items as hazardous waste is not practical or necessary15. Despite this, state policies vary greatly15. Although regulations are fragmented and lack systematic standards, there is rising interest in improving waste practices. Select health-care systems both within the U.S. and internationally have begun investing in climate-smart and sustainable initiatives, exemplified by Kaiser Permanente’s target to become carbon net positive by 2025 and the U.K. National Health Service’s goal of a 34% GHG emission reduction by 202016 (which has been achieved according to a recent report17). Additionally, individual organizations are uniting in an effort to reduce the medical field’s impact on climate change. The Health Care Climate Challenge, a coalition representing 22,000 hospitals and health centers in 33 countries, calls to “reduce the amount of all waste generated, to reduce the toxicity of waste by making smarter purchasing decisions upstream, and by properly segregating and recycling waste.”18 Future Directions Education is the first step in creating a more renewable system of health-care supplies and materials. Learning the nuances of sorting, storage, transportation, and the recovery processes of the varied waste systems is no easy task, but it is a vital step in creating a less-complex health-care waste system. A recent article assessing hand surgeries that are performed in the OR called for “using clear bags during surgical preparation and red bags right before the procedure to segregate operating room waste properly.”19 Simple methods such as these can better the efficiency, cost-effectiveness, and ease of creating sustainable practices. Another potential strategy is to decrease the mix of materials that are used in hospitals so that those used are easily sorted and managed for recycling and created in large enough quantities to be viable for recycling programs. Product design needs to ensure not only functionality and safety but also reusability or recyclability. Staff training, logistical planning, and practice reevaluation by health-care systems are needed to better understand and improve practices. Open communication between waste collectors and hospitals is crucial in order to smoothly and efficiently create best practices. Although governmental legislation and large corporations are focusing first on the sustainability of consumer goods, the health-care industry is not exempt from initiatives to reduce the use of fossil fuel, GHG emissions, landfill overflow, incinerator pollution, and the litter that is plaguing our oceans and soil20. Next-generation materials for health-care products and packaging should be considered as the movement for more environmentally friendly practices and materials grows. Innovations in the plastics industry are working to scale up the use of post-consumer recycled plastic in medical device and packaging applications21. More stringent standards for these materials in medical use may be needed, but this should not hinder the need to transition to climate-smart products. A surgeon’s focus has always been centered on patient health. As climate change progresses and the health of many is affected, the focus of the health-care community needs to incorporate the environmental consequences of patient-care decisions. The health threat of climate change is said to be the “greatest global health opportunity of the twenty-first century,” indicating the potential for positive impact with improved waste practices16. As leaders in the OR, surgeons are called on to advocate for climate change mitigation through improved waste education and management. The health of our patients and planet depends on it.

Topics & Concepts